Prescott was invited to join a targeted PrEP program. Run by the BC Centre for Excellence in HIV/AIDS, it aimed to track HIV outbreaks, and offered PrEP free to everyone near an epicentre.

At first, the 24-year-old gay man living in Kelowna, BC, hesitated. After all, his boyfriend had an undetectable viral load; he knew he couldn’t contract the virus from him. But when Prescott realized how few young gay people in his part of the province knew about PrEP, he decided to take it anyway. He wanted a conversation starter.

“There are no real events that don’t involve alcohol or aren’t 19 plus,” he says. “They’re all centred around partying and having a good time, and there’s no real gatherings other than that. There are no book readings, or places where people can just talk. It’s all doors open at 11pm.”

Working in a harm reduction shelter on Leon Avenue in downtown Kelowna, Prescott says he brings up his experience taking PrEP every time he talks about HIV. He says knowledge about the virus is scarce, both among the shelter’s staff and residents. Some of his co-workers misguidedly wear masks and gloves out of fear of HIV infection.

Prescott’s experience underscores one of the next challenges in battling HIV in British Columbia. Pre-exposure prophylaxis may now be free, but that doesn’t mean it’s accessible to the half of BC’s population living outside of Vancouver and the Fraser Valley.

A lack of doctors, information, education and community support still make taking PrEP an uphill battle in rural British Columbia, where a quarter of the province’s new HIV infections take place.

Drive an hour and a half south on Highway 33 from where Prescott lives in Kelowna and turn east through the Kettle Valley and you’ll find yourself in Robin Van Stolk’s territory. Van Stolk, an HIV outreach nurse, travels from Midway through Nelson and Cranbrook and as far north up Kootenay Lake as Argenta, teaching people about HIV and giving basic medical care from performing blood pressure tests to patching up cuts.

But Van Stolk says the hardest part isn’t reaching the remote communities he serves, it’s gaining their trust. Groups at high risk for HIV such as gay and bisexual men don’t like to make themselves visible in rural communities.

“It’s not just that the communities are hidden, but that they want to stay hidden,” Van Stolk says. “You can’t just walk up to anyone and say, ‘Do you want an HIV test?’ There’s a lot of stigma.”

While provincial coverage of PrEP will make the drug easier to promote, Van Stolk says, there are still plenty of barriers. He still hasn’t found a doctor in the Kootenays willing to prescribe PrEP or take on the quarterly check-ups the drug requires.

Stigma also stands in the way. Van Stolk says for every 40 posters he puts up offering needle exchanges or HIV tests, 30 are torn down within the week.

The best demonstration that subsidizing PrEP isn’t enough to make it accessible comes from farther north, in the territory roamed by Orlando Mcleish.

Mcleish is an HIV educator at Positive Living North, an HIV support organization in Prince George. The majority of people Mcleish works with are Indigenous, and have in theory had free access to PrEP for years through British Columbia’s First Nations Health Authority. Nevertheless, very few have taken advantage of the program.

As he travels through northern BC, Mcleish says he’s not surprised to find that few people have accessed PrEP. Most of the people he speaks with have never heard of the drug.

Mcleish teaches HIV education classes from Dawson Creek to Prince Rupert, sometimes visiting communities of a few hundred people a 16-hour drive away from his office. Mcleish’s landscape is the size of France with the population of the city of Burnaby. It also has the highest per capita rate of HIV infection outside Metro Vancouver.

“It’s not talked about a lot,” he says. “People say, why not just wear a condom? Why not just have healthier sexual practices? And that leads us into a discussion. Especially in the small communities, where it’s more religiously based, it can be harder to have that conversation.”

What’s more, many small communities only see a travelling medical practitioner once or twice a month for everything from injuries to hepatitis C treatment. Many people feel that dealing with HIV prevention is last on their list of priorities.

In one small community, Mcleish says he spoke to an HIV-positive gay man with an HIV-negative partner who told him, “‘Orlando, I have so much stuff to deal with. I’ll let my partner know if he wants to take it, but I have this to deal with and I have that to deal with, and and figuring out something like PrEP is last on our list.”

Many doctors and nurses in the North also lack training in PrEP, Mcleish says, and some scare away those who ask with rumours of dangerous side effects.

Orlando Mcleish travels throughout Northern British Columbia teaching HIV prevention, but stigma and a shortage of medical care make his work an uphill battle. Credit: Courtesy Orlando Mcleish

Mcleish and other workers at Positive Living North know of only one doctor in northern BC, in the region’s largest city Prince George, who will prescribe PrEP.

When the BC government announced it would cover PrEP in December 2017, Xtra asked Health Minister Adrian Dix about the shortage of trained medical practitioners who could prescribe the drug, especially in rural areas. Dix said the problem with PrEP is the same as the problem facing nearly every facet of medical care in the province: the scarcity of family doctors.

“There are hundreds of thousands of people who are unattached from a primary care provider, and many of those issues have social dimensions,” Dix said. “There are broader questions we have to address.”

Despite the challenges, both Van Stolk and Mcleish are hopeful about the future of PrEP in rural BC. They say educating doctors about PrEP is a key first step, along with training nurses and outreach workers to do more of the groundwork of testing and checking up on patients.

The biggest challenge, they say, will be the shift required in attitudes around HIV.

“[PrEP] is free and that’s a big step forward,” Mcleish says. “But we also have to talk about how, for a lot of rural communities, for a lot of LGBT men, they don’t feel comfortable talking to family physicians or to healthcare providers about certain things. It’s very awkward.”